Dr. Charles Crutchfield in Dermatology Times Article

Optimize outcomes in patients with skin of color by tailoring therapies

National report — When treating patients with skin of color, dermatologists face a number of challenges, and they must choose products and therapies carefully.

A 55-year-old female patient before (left) and after treatment with liquid facelift, dermatosis papulosa nigra surgery, Pixel laser and the Skin Active Skin Care Program (NeoStrata). (Photos: Charles E. Crutchfield III, M.D.)
Diagnosis is the first challenge; common dermatological conditions may have a slightly different appearance in skin of color, depending on the hue of a patient’s skin, says Charles Crutchfield III, M.D.
“If you’re used to something looking pink or red and then you see it in brown skin, it looks completely different,” says Dr. Crutchfield, clinical professor of dermatology, University of Minnesota Medical School, Minneapolis/St. Paul, and medical director of Crutchfield Dermatology, Eagan, Minn.

Furthermore, dermatologists will encounter a number of conditions more commonly found in patients with skin of color, such as papular pityriasis rosea, razor bumps and keloids, he explains.

“One of the most significant things is the postinflammatory discoloration, both lighter and darker, that you see in skin of color,” Dr. Crutchfield says. “Any time there is inflammation or injury you can have dramatic change in skin color — usually darker, but sometimes lighter, that has to be managed. Sometimes it can take months to correct.”

Weighing options

To help prevent postinflammatory hyperpigmentation, it’s important to choose the right skincare products, says Zoe Draelos, M.D. Preparations that are recommended in white patients may not be suitable for patients with skin of color.

“The most important concern that’s different from Caucasian skin is that you have to be sure that the products that you recommend, whether they’re prescription or over-the-counter … cause absolutely no irritation of the skin at all,” says Dr. Draelos, consulting professor of dermatology, Duke University School of Medicine, Durham, N.C., who is also in private practice in High Point, N.C.

For example, Dr. Draelos says, over-the-counter acne products containing benzoyl peroxide can be irritating in Asian, Latino and African-American patients and ultimately darken the skin. In addition, exfoliants containing glycolic acid or scrubs containing granules or beads also can irritate the skin, resulting in postinflammatory hyperpigmentation, she says.

Key Points

• Common dermatologic conditions may have slightly different appearance in skin of color
• Products containing benzoyl peroxide can be irritating in Asian, Latino and African-American patients and may darken the skin
• Moisturizing lotions with ceramides go a long way to correct dermatitis associated with dry skin

Managing acne

In patients with acne, Dr. Crutchfield explains to them that postinflammatory changes can be a particular problem with skin of color. Therefore, they need to understand that he must address the inflammatory papules and pustules as well as the postinflammatory hyperpigmented macules that remain after acne heals. Unfortunately, patients with these macules often believe their acne has returned.

In addition to relying on products that are not irritating, Dr. Crutchfield uses anti-inflammatory products to prevent irritation. To manage dyspigmentation, he uses a combination of alpha hydroxy acids and high-dose hydroquinone or hydroquinone metabolites. He also uses a product compounded by his pharmacist that contains hydroquinone, vitamin C, retinol, kojic acid and a steroid.

A number of new products are being used to manage dyspigmentation of the skin. “Many companies are trying to get away from hydroquinone because of the safety issues that have been raised,” Dr. Draelos says. Therefore, physicians are turning to products such as arbutin and deoxyArbutin, kojic acid, lignin peroxidase (Elure, Syneron/Candela), and licorice extract products such as glycyrrhizic acid, she says.

“Sometimes, people will use a bearberry extract if they’re looking for something in the botanical realm,” she adds.

To address concerns in this population, Dr. Draelos says, cosmetic companies are testing products in people with skin of color before they go on the market. “Usually when we test a new cosmetic, we use a broad, multiethnic panel,” she says.

Furthermore, companies work to formulate products with ingredients that have a low potential for irritation and may include an anti-inflammatory to prevent irritation before it occurs, she adds.

Optimizing results

When treating dyspigmentation, Dr. Draelos educates patients about the importance of using sunscreens. “If the sun is darkening the skin and you’re using these products to try to lighten the skin, you find that you end up nowhere,” she says. “So sunscreen is very, very important, and sun avoidance is very important also.”

To maintain skin quality and health, Dr. Crutchfield also suggests moisturization and hydration. “I recommend a good moisturizing lotion that contains ceramides at least twice a day, but especially after bathing,” he says. “That goes a long way to correct dermatitis associated with dry skin.”

He suggests a combination of CeraVe Moisturizing Cream (Coria) and Vanicream Cleansing Bar (Pharmaceutical Specialties), which doesn’t strip away the skin’s natural oils.

Dr. Draelos says she finds that patients with skin of color often want to try other products.

“So I tell them to put a very, very small amount in front of their ear for five nights in a row, and if they have no trouble there, then they can use it broadly over their face.”

Following this course can sometimes prevent overall facial problems. “Predicting a problem before it occurs is always the best way to deal with it,” she says.

Disclosures: Drs. Crutchfield and Draelos report no relevant financial interests.

Optimize outcomes in patients with skin of color by tailoring…